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EFFECTIVENESS OF NUTRITION
INTERVENTIONS IN LOW AND MIDDLE-
INCOME COUNTRIES: AN EVIDENCE
SUMMARY
RAPID EVIDENCE ASSESSMENT PROTOCOL, JUNE 2016
[Insert photo attribution]
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The authors of this report are:
1. Dileep Mavalankar, MD, PhD Director, & Vice-president (Western region), Indian Institute of Public Health Gandhinagar (IIPHG), Ahmedabad, Gujarat, India
2. Shuby Puthussery, PhD Senior Lecturer in Public Health, Department of Clinical Education and Leadership & Institute for Health Research, University of Bedfordshire, Bedfordshire, UK
3. Kavitha Menon, PhD Associate Professor, Indian Institute of Public Health Gandhinagar (IIPHG), Ahmedabad, Gujarat, India
4. Ritu Rana, PhD
Assistant Professor, Indian Institute of Public Health Gandhinagar (IIPHG), Ahmedabad, Gujarat, India
5. Janine Bhandol, MLISc
Librarian, University of Bedfordshire, Bedfordshire, UK 6. Sabuj Kanti Mistry, MPH
Senior Research Associate, Research and Evaluation Division, BRAC Centre, Dhaka, Bangladesh 7. Anal Ravalia, BAMS, MSc
Programme Assistant, Indian Institute of Public Health Gandhinagar (IIPHG), Ahmedabad, Gujarat, India
8. Pei-Ching Tseng, MSc Research Assistant, Department of Clinical Education and Leadership & Institute for Health Research, University of Bedfordshire, Bedfordshire, UK
Funding
This is an independent report commissioned and funded by the Research and Evidence Division in the
Department for International Development. This material has been funded by UK aid from the UK
Government, however, the views expressed do not necessarily reflect the UK Government’s official
policies.
Acknowledgments
We acknowledge the Indian Institute of Public Health Gandhinagar and the Public Health Foundation
of India for logistics support, the UK Department for International Development for the grant to
conduct the present work, the EPPI Centre for technical support and the PwC for their co-ordination
of the whole process.
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Conflicts of interest
None declared
Contributions
The opinions expressed in this publication are not necessarily those of the EPPI-Centre/3IE or the
funders. Responsibility for the views expressed remains solely with the authors.
Citation
This report should be cited as: Mavalankar D, Puthussery S, Menon K, Rana R, Bhandol J, Mistry S,
Ravalia A, Tseng P, (2016), Effectiveness of nutrition interventions in low and middle income countries:
An evidence summary. Protocol. London: EPPI-Centre, Social Science Research Unit, UCL Institute of
Education, University College London
Picture
Cover Picture Source: World Bank, Photo Collection, Country: Bangladesh, Photographer: Shehzad Noorani,2002 http://secure.worldbank.org/photolibrary/servlet/main?contentMDK=90012062&piPK=145042&startIndex=793&theSitePK=265652&pagePK=145040&menuPK=430504&imgfilename=SNO0024BAN Back picture Source: World Bank, Photo Collection, Country: Nepal, Photographer: Curt Carnemark,1992 http://secure.worldbank.org/photolibrary/servlet/main?contentMDK=90014204&piPK=145042&startIndex=649&theSitePK=265652&pagePK=145040&menuPK=430504&imgfilename=NP030S08
© Copyright
Authors of the systematic reviews on the EPPI-Centre website (http://eppi.ioe.ac.uk/) hold the
copyright for the text of their reviews. The EPPI-Centre owns the copyright for all material on the
website it has developed, including the contents of the databases, manuals, and keywording and
data-extraction systems. The centre and authors give permission for users of the site to display and
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CONTENTS
1 Background ........................................................................................... 6
2 Methods ............................................................................................. 14
3 Timetable ........................................................................................... 19
References ............................................................................................... 207
Appendix .................................................................................................. 19
APPENDIX 1.1: AUTHORSHIP OF THIS REPORT ..................................................... 19
APPENDIX 2.1: Inclusion and exclusion criteria ................................................... 20
APPENDIX 2.2: List of Databases .................................................................... 22
APPENDIX 2.3: Search strategy ...................................................................... 23
APPENDIX 2.4: Quality assessment tool ............................................................ 27
APPENDIX 2.5: Data extraction tool ................................................................ 29
APPENDIX 2.6: List of stakeholders ................................................................. 34
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LIST OF ABBREVIATIONS
BMGF Bill and Melinda Gates Foundation
BMI Body Mass Index
BRAC Bangladesh Rehabilitation Assistance Committee
CINI Child in Need Institute
DFID The Department for International Development
FANTA Food and Nutrition Technical Assistance Project
FAO Food and Agriculture Organization of the United Nations
FHI360 Family Health International
FNB Food and Nutrition Bulletin
GAIN Global Alliance for Improved Nutrition
GNR Global Nutrition Report
ICCIDD International Council for Control of Iodine Deficiency Disorders
IDA Iron Deficiency Anaemia
IDS Institute of Development Studies
IFPRI International Food Policy Research Institute
LANSA Leveraging Agriculture for Nutrition in South Asia
LMICs Low and Middle Income Countries
MDGs Millennium Development Goals
MI Micronutrient Initiative
MoH Ministry of Health
RUTF Ready to Eat Therapeutic Foods
SAM Severe Acute Malnutrition
SDGs Sustainable Development Goals
SPRING The Strengthening Partnerships Results and Innovations in Nutrition Globally Project
SR Systematic Review
SUN Scaling Up Nutrition
TN Transform Nutrition
UNICEF United Nations Children's Emergency Fund
USAID United States Agency for International Development
WFP World Food Programme
WHO World Health Organization
WHZ Weight for Height Z scores
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1 BACKGROUND
1.1 DESCRIPTION OF THE PROBLEM
Undernutrition remains as an unfinished agenda for the majority of low and middle-income countries
(LMICs). The UNICEF defined undernutrition as the outcome of insufficient food intake and repeated
infectious diseases. It includes being underweight for one's age, too short for one's age (stunted),
dangerously thin for one's height (wasted) and deficient in vitamins and minerals (micronutrient
malnutrition) (UNICEF, 1990).
The prevalence of undernutrition cuts across the different segments of populations and the
vulnerable groups exposed to different levels of undernutrition include children, adolescent girls,
women of reproductive age, elderly and socioeconomically disadvantaged groups. These vulnerable
groups from LMICs have higher prevalence of undernutrition that manifest as moderate to severe
forms. Globally around 165 million children under the age of five suffer from stunting (low height-for-
age), 101 million are underweight (low weight-for-age) and 52 million children are wasted (low
weight-for-height). Approximately 90 % of these children live in just 36 countries with the highest
prevalence in Southeast Asia and Sub-Saharan Africa (Das et al, 2015). Further, South Asia has the
highest prevalence of underweight among adolescent girls of 15-18 years increasing annually by
0.66% in rural areas. On the contrary, the Latin American and the Caribbean countries showed higher
regional prevalence of overweight in both rural and urban settings with this prevalence increasing
annually by about 0.50% (Jaacks et al, 2015). In urban areas, 38% of countries had both an under- and
overweight prevalence ≥10% (Jaacks et al, 2015). Additionally, the prevalence of low BMI (<18·5
kg/m²) in adult women remains higher than 10% in Africa and Asia (Black et al, 2013). The prevalence
of single or coexisting micronutrient deficiencies together termed as “hidden hunger” in the
populations of LMICs, predominantly of iron, vitamin A and zinc continues as a major public health
challenge. The older women are often regarded as neglected part of the communities with high
prevalence of undernutrition. About a half of the Bangladeshi older adults had chronic energy
deficiency and 62% were at risk of malnutrition (Kabir et al, 2006). Collectively, the above data
indicate a double burden of nutritional issues- prevalence of undernutrition and obesity in the
vulnerable populations- as a result of nutrition transition.
Risk factors of undernutrition are complex; include national scale determinants to individual specific,
and factors which effect at various age and period of life (Scaling up of Nutrition, 2011). The UNICEF
conceptual framework on the causes of malnutrition suggests that aetiology of undernutrition is
multifactorial, complex and intricate. The framework classified the causes of undernutrition to three
categories as immediate causes (i.e. inadequate dietary intake and infectious diseases), underlying
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causes (i.e. insufficient access to food, inadequate maternal and child care, poor sanitation hygiene
and inadequate health services) and basic causes (i.e. the roles of formal and non-formal institutions,
political and ideological superstructure, economic structure and potential resources) (UNICEF, 1998).
Under-over-nutrition can have adverse effects throughout the life cycle and has been considered as a
leading cause of death, disability, and ill-health (WHO, 2013). For example, maternal overweight and
obesity are associated with maternal morbidity, preterm birth, and increased infant mortality. Fetal
growth restriction is associated with maternal short stature and underweight and causes 12% of
neonatal deaths (Black et al, 2008). Being underweight makes it susceptible to infection and longer
duration to recover from illness, and with repeated bouts of infectious diseases estimated 3.1 million
preventable maternal and child deaths occur annually (Black et al, 2013). Stunting (defined by the
WHO as low height-for-age) impair cognitive development, increase susceptibility to infection, and
affect school attainment and future productivity with intergenerational effects (Bhutta et al, 2013).
Further, deficiencies in iron, iodine, zinc, and vitamins can cause problems such as brain damage,
blindness, anaemia, and stunted growth. Undernutrition affects learning abilities, and cause delayed
achievement of developmental milestones in children. In turn, such adults fail to reach their full
growth potentials influencing their socio-economic productivity resulting in poor economic growth
(Hoddinott, 2013).
1.2 DESCRIPTION OF THE INTERVENTIONS TO IMPROVE NUTRITIONAL AND HEALTH STATUS
The global nutrition scenario has changed significantly ever since the constitution of MDGs.
Increasingly, more countries recognize the potentials of good nutrition to strengthen societies and
transform the lives of vulnerable populations, including children, women and socio-economically
disadvantaged populations. As a result, multitudes of interventions to reduce undernutrition at
different stages of lifecycle had been recommended and implemented in various countries, including
the LMICs.
Many adverse effects of undernutrition including morbidities and mortalities in vulnerable
populations could be prevented through timely nutrition interventions. These nutrition interventions
have both preventive and curative purposes, especially in LMICs and scaling up of these valuable
interventions have shown to be hugely beneficial to the millions of populations (Bhutta et al, 2013).
The Lancet (2013) series on maternal and child health examined these multitudes of interventions
that were implemented in 34 countries and ascertained that scaling up of these interventions reduce
deaths in children younger than five years by 15% (Bhutta et al, 2013).
The nutrition interventions were categorized to nutrition-specific and nutrition-sensitive
interventions.
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Nutrition-specific interventions refer to those programmes and approaches that have direct impact
on nutritional outcomes and address the immediate causes of undernutrition (i.e. inadequate food
intake, poor feeding and care practices and high burden of infectious diseases). The ten nutrition-
specific interventions with evidence for effectiveness of nutrition interventions and delivery
strategies identified included supplementation of folic acid, calcium, balanced protein-energy and
micronutrients to pregnant women; promoting breast feeding and delivering appropriate
complementary feeding to infants, providing vitamin A and zinc supplements to children up to the
age of five; and using proven treatment strategies to manage moderate to severe malnutrition in
children.
Nutrition-sensitive interventions and programmes include programmes that address some of the
underlying determinants of nutrition (e.g. poverty, food insecurity, poor health, gender inequity,
etc.). Nutrition-sensitive interventions include agriculture, home gardens and homestead
production systems, biofortification, social safety nets, conditional and unconditional cash
transfers, school feeding programmes, household food distributions, early child development and
schooling.
The above interventions could be delivered through a wide variety of platforms providing enough
opportunities to scale up these strategies to reach large number of these socioeconomically
disadvantaged and vulnerable populations in LMICs. The different platforms include fortification of
staple foods to reach large segments of populations; cash transfer programmes to reduce poverty,
reduce financial barriers, and to improve population health; community based platforms for nutrition
education and promotion aimed to promote behaviour change; community mobilization strategies to
promote health care; integrated management of childhood illnesses strategies to improve healthcare
practices at health facilities and home; school based delivery platforms to reach children >5 years of
age to improve nutritional status through feeding programmes while promoting school enrolment;
and child health days to deliver nutrition interventions such as vitamin A supplements,
immunizations, insecticide-treated nets and deworming drugs (Bhutta et al, 2013).
Implementation of nutrition-specific interventions may appear to be simple, cost-effective and
straight forward to improve the nutritional status of different populations, however, delivery, uptake
and utilization of such interventions are extremely complex to achieve the desired outcomes. The
implementation of these interventions are often influenced by several factors including behavioural,
contextual, social, access and system barriers (Middleton et al, 2012). Some of such programmes
made limited impact on the expected outcomes due to complex social environments, poverty and lack
of access to quality food items, gender inequalities, social beliefs and lack of opportunities to
participate in decision making process.
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1.3 BENEFITS OF NUTRITION INTERVENTIONS
Nutrition interventions are primarily aimed to improve the nutritional status of populations
augmenting their dietary intakes to achieve optimal/desirable intakes of various nutrients. Nutrition-
specific interventions such as direct supplementation of various nutrients (i.e. balanced protein-
energy, calcium, iron, folic acid, vitamin A, zinc, iodine etc.) aims to improve the intakes of these
nutrients to prevent nutrient deficiencies in different populations including women and children. The
majority of populations living in LMICs have limited access to nutrient dense foods, such interventions
are beneficial as they subsist on predominantly cereal-pulse based diets that are insufficient to
adequately provide many of these nutrients.
Supplementation of folic acid to women of reproductive age has shown 72% reduction in risk of
development of neural tube defects (De-Regil et al, 2010); daily iron supplementation during
pregnancy reported 70% reduction in anaemia at term, 67% reduction in iron deficiency anaemia
(IDA), and 19% reduction in the incidence of low birthweight (Pena-Rosas, 2012); multiple
micronutrient supplementation reported 11–13% reduction in low birthweight and SGA births
(Haider and Bhutta, 2012); calcium supplementation during pregnancy reduced the incidence of
gestational hypertension by 35%, preeclampsia by 55%, and preterm births by 24% (Hofmeyr et al,
2010); iodised oil supplementation in pregnancy in severe iodine deficient populations showed a 73%
reduction in cretinism and a 10–20% increase in developmental scores in children, (Zimmermann,
2012); and balanced energy-protein supplementation during pregnancy increased birthweight by 73g
(95% CI 30–117) and reduced risk of SGA by 34%, with more pronounced effects in malnourished
women (Imdad and Bhutta, 2012).
In neonates, breast feeding initiation within 24 h of birth was associated with a 44–45% reduction in
all-cause and infection-related neonatal mortality (Debes et al, 2013); in children between 6 to 23
months of age consumption of a minimum acceptable diet with dietary diversity reduced the risk of
both stunting and underweight (Marriott et al, 2012); vitamin A supplementation reduced all-cause
mortality by 24% and diarrhoea-related mortality by 28% in children aged 6–59 months (Imdad et al,
2010); intermittent iron supplementation to children younger than 2 years reduced the risk of
anaemia by 49% and iron deficiency by 76% (De-Regil et al, 2012); and preventive zinc
supplementation reduced the incidence of diarrhoea by 13% and pneumonia by 19%, with a non-
significant 9% reduction in all-cause mortality (Yakoob et al, 2011).
Evidence from studies that compared ready-to-use therapeutic foods (RUTF) with standard care in
community based management of severely acutely malnourished (SAM) children showed no effects
on reduction mortality; however, children who received RUTF had faster rates of weight gain and had
51% greater likelihood to recover (defined as attaining WHZ ≥ –2) than did those receiving standard
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care (Lenters et al, 2013). In a landmark randomized control trial in children with uncomplicated SAM
that compared standard RUTF with RUTF and additional 7 day course of antibiotics showed a lower
mortality rate, faster recovery rate, and higher weight gain in children who received an antibiotic
compared with children receiving placebo (Trehan et al, 2013).
Table 1: Summary of evidence for nutrition-specific interventions
Interventions Findings
Supplementation of folic acid to women of reproductive age
Has shown 72% reduction in risk of development of neural tube defects (De-Regil et al, 2010)
Daily iron supplementation during pregnancy
Reported 70% reduction in anaemia at term, 67% reduction in iron deficiency anaemia (IDA), and 19% reduction in the incidence of low birthweight (Pena-Rosas, 2012)
Multiple micronutrient supplementation Reported 11–13% reduction in low birthweight and SGA births (Haider and Bhutta, 2012)
Calcium supplementation during pregnancy
Reduced the incidence of gestational hypertension by 35%, preeclampsia by 55%, and preterm births by 24% (Hofmeyr et al, 2010)
Iodised oil supplementation in pregnancy in severe iodine deficient populations
Showed a 73% reduction in cretinism and a 10–20% increase in developmental scores in children, (Zimmermann, 2012)
Balanced energy-protein supplementation during pregnancy
Increased birthweight by 73g (95% CI 30–117) and reduced risk of SGA by 34%, with more pronounced effects in malnourished women (Imdad and Bhutta, 2012).
In neonates, breast feeding initiation within 24 h of birth
Was associated with a 44–45% reduction in all-cause and infection-related neonatal mortality (Debes et al, 2013)
In children between 6 to 23 months of age consumption of a minimum acceptable diet with dietary diversity
Reduced the risk of both stunting and underweight (Marriott et al, 2012)
Vitamin A supplementation Reduced all-cause mortality by 24% and diarrhoea-related mortality by 28% in children aged 6–59 months (Imdad et al, 2010)
Intermittent iron supplementation to children younger than 2 years
Reduced the risk of anaemia by 49% and iron deficiency by 76% (De-Regil et al, 2012)
Preventive zinc supplementation Reduced the incidence of diarrhoea by 13% and pneumonia by 19%, with a non-significant 9% reduction in all-cause mortality (Yakoob et al, 2011).
Ready-to-use therapeutic foods (RUTF) with standard care in community based management of severely acutely malnourished (SAM) children
Showed no effects on reduction mortality
Children who received RUTF Had faster rates of weight gain and had 51% greater likelihood to recover (defined as attaining WHZ ≥ –2) than did those receiving standard care (Lenters et al, 2013).
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Children with uncomplicated SAM that compared standard RUTF with RUTF and additional 7 day course of antibiotics
Showed a lower mortality rate, faster recovery rate, and higher weight gain in children who received an antibiotic compared with children receiving placebo (Trehan et al, 2013)
Nutrition-specific interventions are short-term strategies and are aimed to combat issues of
undernutrition through targeted approach of supplementation of nutrients to the specific groups of
populations. The sustainability of such interventions/ programmes are often a great challenge and
needs huge investments. A more prudent approach would be to have a combination of both nutrition-
specific and nutrition-sensitive approach in order to improve the dietary intakes of nutrients and thus,
nutritional status indirectly.
Nutrition-sensitive programmes aid to accelerate improvements in nutritional status by augmenting
household and community environments, protecting the poor from the adverse implications of food
security threats and climate change (Ruel et al, 2013). Targeted agricultural programmes can
influence nutrition through key mediators including women’s social status, empowerment, control
over resources, time allocation, and health and nutritional status (World Bank, 2007; Gillespie et al,
2012). The effects of homestead food production systems on intermediary outcomes along the impact
pathway, showed positive effects on household production and consumption, maternal and child
intake of target foods and micronutrients, and overall dietary diversity (Leroy et al, 2008).
Biofortification strategies are found to be successful in improving the dietary intakes of different
micronutrients such as vitamin A, iron and zinc, contributing to achieve adequate intakes of these
deficient nutrients. The majority of these nutrition-sensitive programmes improve the food
availability and food consumption, thus, favouring adequate food intakes, increase dietary diversity to
ensure appropriate nutrient intakes in the vulnerable populations.
Table 2: Summary of evidence for nutrition-sensitive interventions
Interventions Findings
Targeted agricultural programmes Can influence nutrition through key mediators including women’s social status, empowerment, control over resources, time allocation, and health and nutritional status (World Bank, 2007; Gillespie et al, 2012)
Homestead food production systems on intermediary outcomes along the impact pathway
Showed positive effects on household production and consumption, maternal and child intake of target foods and micronutrients, and overall dietary diversity (Leroy et al, 2008).
Biofortification strategies Found to be successful in improving the dietary intakes of different micronutrients such as vitamin A, iron and zinc, contributing to achieve adequate intakes of these deficient nutrients.
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1.4 RATIONALE
Evidence summaries harvested from existing systematic reviews (SRs) and meta-analyses help to
consolidate the available evidence in a specific area to support evidence-based policy formulations
and implementation of programmes that might benefit the vulnerable populations, especially in the
LMICs. The development of evidence summaries not only support formulation of policies but also
these evidence generated could be contextualized country-specific or region specific to improve the
health outcomes of the populations. Additionally, such summaries provide insights into the
availability/non-availability of the existing evidence in a particular theme or area of research.
Under- and over-nutrition issues in vulnerable populations continue as a major public health
challenge that adversely impact nutritional and health status of populations; in its severe forms
results in morbidity and mortality. These nutrition issues are preventable with timely interventions
and support in a cost-effective way. The Lancet maternal and child health series (2013) showed
multiple benefits of scaling up of nutrition-specific and nutrition-sensitive interventions in reducing
maternal and child mortality. The evidence from the above series politically and socially motivated the
implementation of large scale nutrition programmes or interventions in many developing countries,
especially as an attempt to achieve target of MDGs-reducing maternal and infant mortality by 2015.
There are many nutrition interventions implemented globally, especially in developing countries to
improve health and nutrition status of the vulnerable and/or socioeconomically disadvantaged
populations. The impact of these nutrition interventions have been positive, however they had
inherent challenges at the implementation level that influenced the uptake and delivery.
Subsequently, in different developing country settings these interventions showed mixed results due
to inherent challenges in access, availability, implementation, delivery and uptake by different
segments of populations. Thus, the majority of undernutrition challenges remain as unfinished
agenda in LMICs. Additionally, more evidence from research emerged in the last few years regarding
potential new interventions and the innovative delivery platforms for implementation of these
targeted interventions that might improve the nutrition and health status of socioeconomically
disadvantaged populations.
In this scenario, it may be prudent to gather more evidence to critically analyse and identify key
characteristics of successful interventions in LMICs and contextualize it to South Asian countries and
particularly Bangladesh. Developing country-specific evidence on potential interventions would be of
interest to policy makers in LMICs, as policy making decisions are often spontaneous without
adequate evidence. Further, the results from such evidence summaries might be a foundation for
many developing countries to implement evidence-based country-specific nutrition interventions to
improve the health and nutrition status of populations in a most culturally and socially appropriate
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way. This approach would allow the countries to revisit and strengthen these nutrition interventions
to achieve nutrition related (Goal 2) targets of SDG by 2025.
1.5 RESEARCH AIMS AND REVIEW QUESTIONS
The aim of this meta-review will be to identify, critically appraise and provide an overview of review-
level evidence on the effectiveness of nutritional interventions delivered in LMICs. This will be
achieved by addressing the following primary research question:
a. Primary question: What review-level evidence exists on the effectiveness of nutrition interventions
in LMICs?
Depending on the nature and extent of the evidence-base on the effectiveness of nutritional
programmes in LMIC’s it may be possible to provide further review-level evidence to answer the
following research questions:
b. Secondary questions
1. What types of nutrition interventions aimed at improving nutritional and health status of the
general population in LMICs are shown to be effective?
2. What review-level evidence exists on the factors potentially contributing to the success or failure
of nutritional interventions in LMIC?
3. Is there review-level evidence on nutrition interventions specific to urban settings in LMICs? If so,
what are the key characteristics of successful nutrition intervention programmes delivered in
urban settings?
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2 METHODS
2.1 ADVISORY GROUP INVOLVEMENT
We have established a multidisciplinary review team and advisory group (Appendix 1.1) with
significant experience of nutrition programs in South Asia. These members were involved in
developing and finalising the protocol. Additionally, we will include two members from DFID as well
in the advisory group. We will engage with the advisory group throughout the different stages of the
review through different channels of communication such as emails, telephone and skype to get their
input and feedback on search terms, screening, data extraction tool, synthesis, final report writing
and dissemination of study findings. Depending on the feasibility, we may hold one face to face
meeting with the advisory group during the final stages of the review.
2.2 DEFINING RELEVANT REVIEWS: INCLUSION CRITERIA
All located citations will be assessed first on the basis of title and abstract. The full publication of those
meeting inclusion criteria (Appendix 2.1) will be retrieved and assessed again for inclusion. For
systematic review citations to be included on title and abstract, studies must:
Language: be published in English, in order to be completed within the limited time boundary of the
project.
Types of Studies:
Have used explicit and systematic methods to identify studies. E.g. have searched at least two
electronic databases and included a method describing how the studies were included. Depending on
the quality of the reviews, we synthesise primary evidence on the effectiveness of nutrition programs
in LMICs and draw conclusions based on findings from individual studies irrespective of the study
designs of the included primary studies.
Population: include the general population of low and middle-income countries with a specific focus
on vulnerable groups such as children, women and other socio-economically disadvantaged groups.
Low and middle income countries will be classified according to the World Bank definition (World Bank,
2016).
Interventions: aim to tackle issue of under-nutrition by improving dietary intake of beneficiaries
including both nutrition specific and nutrition sensitive approaches and programmes. The Comparators
will include all SRs irrespective of they had a comparison group or not.
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Outcomes will include primary outcome measures that reflect nutritional and dietary intake (weight for
age, height for age, BMI etc.), and health status indicators (haemoglobin, diarrhoea, respiratory tract
infection, etc.) of targeted population groups. Secondary outcome measures will include factors which
affect dietary intake (income, feeding practices, food habits, dietary diversity, access to food etc.).
This PICOS: Participants, Interventions, Comparators, Outcomes, and Study design framework
formulates the overall scope and criteria for inclusion of reviews in the evidence summary.
2.3 IDENTIFYING REVIEWS: SEARCH STRATEGY
We will conduct a comprehensive search both electronically and manually to identify published and
unpublished SRs. During the protocol workshop, the project team and the consultant had extensive
discussions on databases to be searched and potential key words to be used for this evidence
summary. Thus developed lists of databases and key words are provided in Appendix 2.2 and 2.3
respectively. This includes specialist databases for SRs such as the Cochrane Collaboration, Joanna
Briggs Institute, Database of Abstracts of Reviews of Effects, DFID, and PROSPERO, searches will be
conducted on PubMed, PsycINFO, CINAHL, Web of Science, IBSS, HINARI, EPPI-Centre-Evidence, and
the libraries of the authors' institutions and online resources such as Google. We will use the EPPI
reviewer 4 from EPPI-centre, UK to export the citations produced. Duplications will be removed using
EPPI reviewer.
Detailed electronic searches will also be conducted in relevant reports, conference proceedings and
other unpublished grey literature. A sample of stakeholders from the South Asia region including
academics and experts in the field of nutrition; policy makers from relevant government departments
and representatives from donor agencies, special interest groups and other relevant organisations will
also be contacted for relevant reviews Appendix 2.6. We will also use mediums such as mailing lists
and blog postings to identify unpublished and grey literature.
A combination of text words and MeSH terms will be used to identify reviews along with Boolean
operators using ‘AND’, ‘OR’ and ‘NOT’ to unite and filter the search terms. An example of a search
strategy is provided in Appendix 2.3. We will seek expert advice from EPPI Centre regarding the
suitability of the developed search strategy.
2.4 SCREENING REVIEWS: APPLYING INCLUSION AND EXCLUSION CRITERIA
Two-stage screening process will be adopted to select systematic reviews:
First stage involves screening of all titles and/or abstracts for eligibility and will be done by two
researchers (AR, RR). During this screening, all titles and abstracts that seem to be eligible based on the
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inclusion and exclusion criteria (Appendix 2.1) and those in doubt will be included for next step
screening and relevant full text articles will be retrieved.
Second stage: The retrieved full text articles will be independently screened by researchers (RR, AR,
SM,) against a checklist of inclusion criteria as outline in Appendix 2.1. In case of a discrepancy, a senior
investigator (DM, KM, SP) will be involved to make a decision.
2.5 CRITICAL APPRAISAL AND DATA EXTRACTION
The included SRs will be appraised by the researchers (AR, RR, SM) for quality using the AMSTAR
criteria (Shea et al, 2007). Reviews will be assessed on eleven criteria and these criteria summed,
where 11 represents a review of the highest quality. Categories of quality will be determined as
follows: low (score 0 to 3), medium (score 4 to 7), and high (score 8 to 11). The risk of bias tool is
provided in Appendix 2.4. Studies judged to be of low quality will be included if they are relevant
during data extraction and synthesis stages.
The reviews will be categorised broadly by aspects such as the type of interventions, primary
beneficiaries, quality of studies considered, review methods used, outcomes, recommendations, and
implications for policy and practice. The data extraction will be carried out independently by two
investigators with a predesigned data extraction tool. The data extraction tool includes details of
authors; year of publication; PICOS (population, intervention, comparison, outcomes and study
design); recommendations and implications for policy and practice. The data extraction tool will be
developed and tested for its suitability and usability. A preliminary draft is appended in Appendix 2.5.
We will use a separate tool to extract findings that are of relevance to South Asian region.
2.6 EVIDENCE SYNTHESIS AND REPORTING
Towards the end of data extraction, the project team will discuss and decide the possible analyses.
We will take input from advisory members and the SR consortium. The analysis and reporting strategy
will be finalised during this discussions. Broadly, we will use a narrative numerical synthesis approach
following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA)
guidelines (http://www.prisma-statement.org/statement.htm) to produce the summary report. In
addition to textual commentary, we will incorporate summary tables on characteristics of included
reviews including the geographical area covered and the types and details of nutrition interventions
and outcomes. We envisage categorisations of results in terms of region (rural/urban), population
subgroups, types and methods of interventions and outcomes. We will explore the possibility of
including a summary table of findings of highly relevant primary studies from the SA region. For the
purpose of this review, the South Asian region is described as comprising of Afghanistan, Bangladesh,
India, Nepal, Myanmar and Pakistan.
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In addition to the findings, the summary will include implications for policy and programmatic
development at individual country levels and the South Asia region as a whole. We will also make
recommendations for future research based on identified evidence gaps on key policy concerns.
The senior investigators (DM, KM, SP) will lead on writing the different sections of the report.
2.7 QUALITY ASSURANCE PROCESS
We will adopt different approaches for quality assurance throughout the various stages of the review.
In addition to using standardised tools such as AMSTAR and PRISMA guidelines and the application of
pre designed inclusion and exclusion criteria, the coding/data extraction will be conducted by pairs of
team members working independently and then comparing their decisions to reach consensus. We
will also put in place an additional internal quality assurance mechanism whereby each of the stages
will be overseen by one the three senior investigators (DM, KM, SP) who will independently evaluate
the process and the outputs such as search strategy, list of databases, key words, data extraction
sheet, structure of possible summary tables and summarisation process.
The advisory group members and the EPPI-centre will also be consulted and involved in key activities.
2.8 CONTEXTUALISATION
We will contextualise the findings both in terms of the overall characteristics of the SA region and
individual countries, particularly Bangladesh. This will include stating which findings will be relevant
in the light of the existing policy and programmatic initiatives in the region as well as in individual
countries (For example: India: Iron and folic acid supplementation, Kangaroo mother care, Early
initiation of breast feeding, Vitamin A supplementation, etc.; Bangladesh: Iron and folic acid
supplementation; Pakistan: Iron and folic acid supplementation, use of iodized salt, etc.). The team
includes members with significant experience of nutrition programmes in South Asia and while
developing the original proposal we have had extensive discussions about the potential implication of
this evidence summary to inform policy, practice and future research. In addition, we will seek
feedback from the advisory group and the dissemination workshop participants as well as the SR
consortium. We will also hold discussions with relevant stakeholders in SA including telephonic
interviews with sector experts, regional government officials/advisors, policy-makers, DFID country
advisors, to obtain their views and feedback. We will use templates provided by the EPPI-centre to
develop the contextualisation document.
2.9 DISSEMINATION
The findings will be useful and of interest to a wide range of regional, national and local and
international stakeholders including policy makers, practitioners, academics, donor agencies and
18
nongovernmental organisations in the field of health, nutrition, agriculture, and social policy. The
project will be publicised through marketing support teams of the partner organisations right from
the very beginning through online and print media platforms. All the organisations have a proven
track record in raising awareness of research initiatives through local, national and international
media. In addition to the summary and contextualisation document, other project outputs may
include lay summaries for specific groups as relevant (e.g., leaflets for frontline workers; summaries in
institutional newsletters) as well as for the general media (e.g., press releases; blog postings; columns
in newspapers and magazines); at least one peer-reviewed article in a leading journal; and
presentations at international and national conferences and other events involving sector discussions
including events from DFID/SR consortium. We will hold a one day dissemination workshop in India
towards the end of the study to encourage debate and uptake in the region to a larger extent. This
will include representatives and key officials from relevant ministries (ministers/secretaries) from SA
countries; key academic institutes in the sector; national and international NGOs; donor agencies;
DFID country advisors; representatives from the media and special interest groups (Appendix 2.6). In
addition to presenting the findings, the workshop will include panel discussions and round tables to
offer a platform for stakeholders to exchange information and share ideas pertinent to policy,
practice and future research and to develop specific action plans.
19
3 TIMETABLE
Timetable (some review methods do not include these stages in this order)
Stage of review Start date End date
Preparing the protocol 28-Mar-16 27-Apr-16
Peer review of protocol (allow 2 months) 28-Apr-16 27-Jun-16
Searching for studies 28-Apr-16 19-May-16
Assessing study relevance 13-May-16 27-Jun-16
Extracting data from studies 28-May-16 10-Jun-16
Assessing study quality 11-Jun-16 20-Jun-16
Synthesising studies 21-Jun-16 21-Jul-16
Preparing draft report 31-Jul-16 27-Aug-16
Disseminating draft report (allow 3 months) 28-Aug-16 27-Nov-16
Revising report 27-Sept-16 20-Oct-16
Submission for publication with the EPPI-Centre 28-Oct-16
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REFERENCES
Bhutta, Z. A. Das, J. K. Rizvi, A. Gaffey, M. F. Walker, N. Horton, S. Webb, P. Lartey, A. Black, R. E. (2013). Lancet Nutrition Interventions Review Group; Maternal and Child Nutrition Study Group. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet, 382(9890), 452-477. Black, R. E. Allen, L. H, Bhutta, Z. A. et al, for the Maternal and Child Undernutrition Group. (2008). Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet, 371, 243–260. Debes, A. K. Kohli, A. Walker, N. Edmond, K. Mullany, L. C. (2013). Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. BMC Public Health 13(Suppl 3), S19. De-Regil, L. M. Fernandez-Gaxiola, A. C. Dowswell, T. Pena-Rosas, J. P. (2010). Effects and safety of periconceptional folate supplementation for preventing birth defects. Cochrane Database Systematic Reviews. 10: CD007950. De-Regil, L. M. Jefferds, M. E. D. Sylvetsky, A. C. Dowswell, T. (2011). Intermittent iron supplementation for improving nutrition and development in children under 12 years of age. Cochrane Database Systematic Reviews. 12: CD009085. Gillespie, S. Harris, J. Kadiyala, S. (2012). The agriculture-nutrition disconnect in India: what do we know? IFPRI Discussion Paper 01187. Washington, DC: International Food Policy Research Institute. Haider, B. A. Bhutta, Z. A. (2012). Multiple-micronutrient supplementation for women during pregnancy. Cochrane Database Systematic Reviews. 11: CD004905. Hoddinott, J. Harold, A. Jere R. B. Haddad, L. Horton, S. (2013). The Economic Rationale for Investing in Stunting Reduction. GCC Working Paper Series, GCC 13-08. Hofmeyr, G. J. Lawrie, T. A. Atallah, A. N. Duley, L. (2010). Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Systematic Reviews. 8: CD001059. Imdad, A. Bhutta, Z.A. (2012). Maternal nutrition and birth outcomes: effect of balanced protein-energy supplementation. Paediatric Perinatal Epidemiology. 26 (suppl 1), 178–190. Imdad, A. Herzer, K. Mayo-Wilson, E. Yakoob, M. Y. Bhutta, Z. A. (2010). Vitamin A supplementation for preventing morbidity and mortality in children from 6 months to 5 years of age. Cochrane Database Syst Rev. 12: CD008524. Jaacks, L. M. Slining, M.M. and Popkin, B. M. (2015). Recent trends in the prevalence of under- and overweight among adolescent girls in low- and middle-income countries Pediatric Obesity. 10 (6), 428-435. Das, K. J. Salam, A. R. Bhutta, A. (2016). Malnutrition: A Global Problem. Textbook of Pediatric Gastroenterology, Hepatology and Nutrition. A Comprehensive Guide to Practice. Switzerland: Springer Publications. Kabir, Z.N. Ferdous, T. Cederholm, T. Khanam, M.A. Streatfied, K. Wahlin, A. (2006). Mini nutritional assessment of rural elderly people in Bangladesh: the impact of demographic, socio-economic and health factors. Public Health Nutrition. 9, 968–974.
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Lenters, L. M. Wazny, K. Webb, P. Ahmed, T. Bhutta, Z. A. (2013). Treatment of severe and moderate acute malnutrition in low- and middle-income settings: a systematic review, meta-analysis and delphi process. BMC Public Health. 13(Suppl 3): S23. Leroy, J. L. Ruel, M. Verhofstadt, E. Olney, D. (2008). The micronutrient impact of multisectoral programs focusing on nutrition: examples from conditional cash transfer, microcredit with education, and agricultural programs. Innocenti Review. Marriott, B .P. White, A. Hadden, L. Davies, J. C. Wallingford, J. C. (2012). World Health Organization (WHO) infant and young child feeding indicators: associations with growth measures in 14 low-income countries. Maternal Child Nutrition. 8 (3), 354–370. Pena-Rosas, J. P. De-Regil, L. M. Dowswell, T. Viteri, F.E. (2012). Daily oral iron supplementation during pregnancy. Cochrane Database Systematic Reviews. 12: CD004736. Middleton, P. Crowther, C. Bubner, T. Flenady, V. Bhutta, Z. A. Trach, T. Lassi, Z. (2012). Nutrition interventions and programs for reducing mortality and morbidity in pregnant and lactating women and women of reproductive age: a systematic review. Ruel, M.T. Alderman, H. (2013). Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? The Lancet. 382(9890), 536-51. Scaling Up Nutrition. A framework for action. http://www.unscnorg/files/Announcements/Scaling_Up_Nutrition-A_Framework_for_Actionpdf. Accessed 25 April 2016. Shea, B. J. Wells, G. A. Boers, M. Andersson, N. Hamel, C. Porter, A. C. Tugwell, P. Moher, D. B. L (2007). Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Medical Research Methodology. 15, 7-10. Trehan, I. Goldbach, H.S. LaGrone, L. N. et al. (2013). Antibiotics as part of the management of severe acute malnutrition. New England Journal of Medicine. 368, 425–35. UNICEF. (1990). Strategy for improved nutrition of children and women in developing countries. New York: UNICEF. UNICEF. (1998). The state of the world’s children 1998. New York: UNICEF. World Bank. (2016). Country Income Groups (World Bank Classification), Countryand Lending Groups. Online at http://data.worldbank.org/about/country-and-lending-groups#Lower_middle_income (accessed 27/04/2016). World Bank. (2007). From agriculture to nutrition. Pathways, synergies and outcomes. Washington, DC: The International Bank for Reconstruction and Development. World Health Organization. (2013). MDG1: eradicate extreme poverty and hunger. Available from: http://www.who.int/topics/millennium_development_goals/hunger/en/index.html. Accessed 24 April 2016. Yakoob, M.Y. Theodoratou, E. Jabeen, A. et al. (2011). Preventive zinc supplementation in developing countries: impact on mortality and morbidity due to diarrhea, pneumonia and malaria. BMC Public Health. 11 (suppl 3): S23. Zimmermann, M. B. (2012). The effects of iodine deficiency in pregnancy and infancy. Paediatric Perinatal Epidemiology. 26 (suppl 1), 108–17.
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APPENDIX 1.1: AUTHORSHIP OF THIS REPORT
Authors
1. Dileep Mavalankar, MD, PhD Director, & Vice-president (Western region), Indian Institute of Public Health Gandhinagar (IIPHG), Ahmedabad, Gujarat, India
2. Shuby Puthussery, PhD Senior Lecturer in Public Health, Department of Clinical Education and Leadership & Institute for Health Research, University of Bedfordshire, Bedfordshire, UK
3. Kavitha Menon, PhD Associate Professor, Indian Institute of Public Health Gandhinagar (IIPHG), Ahmedabad, Gujarat, India
4. Ritu Rana, PhD Assistant Professor, Indian Institute of Public Health Gandhinagar (IIPHG), Ahmedabad, Gujarat, India
5. Janine Bhandol, MLISc Librarian, University of Bedfordshire, Bedfordshire, UK
6. Sabuj Kanti Mistry, MPH Senior Research Associate, Research and Evaluation Division, BRAC Centre, Dhaka, Bangladesh
7. Anal Ravalia, BAMS, MSc Programme Assistant, Indian Institute of Public Health Gandhinagar (IIPHG), Ahmedabad, Gujarat, India
8. Pei-Ching Tseng, MSc Research Assistant, Department of Clinical Education and Leadership & Institute for Health Research, University of Bedfordshire, Bedfordshire, UK
Details of Advisory Group membership 1. Dr. Purnima Menon,
Theme Leader, South Asia Nutrition Programmes, International Food Policy Research Institute
2. Dr. Sanjay P Zodpey Director, Public Health Education, Public Health Foundation of India
3. Shri Amit Kumar Ghosh Mission Director, National Health Mission Government of Uttar Pradesh
Details of Review Group membership Not applicable Acknowledgements
We acknowledge the Indian Institute of Public Health Gandhinagar and the Public Health Foundation
of India for logistics support, the UK Department for International Development for the grant to
conduct the present work, the EPPI Centre for technical support and the PwC for their co-ordination
of the whole process.
Conflicts of interest
None declared
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APPENDIX 2.1: INCLUSION AND EXCLUSION CRITERIA
Inclusion Criteria
1. Language: Published in English, in order to be completed within the limited time boundary of the project.
2. Date of publication: Jan 2000 to May 2016 3. Types of SRs:
3.1. Searched at least two electronic databases and included a method describing how the studies were included and/or excluded
3.2. Synthesised primary evidence on the effectiveness of nutrition programs in LMICs and draw conclusions based on findings from individual studies irrespective of the study designs of the included primary studies
4. Population: Include the general population with a specific focus on vulnerable groups such as children, women and other socio-economically disadvantaged groups.
5. Interventions: SRs which have included at least one of these interventions that aim to tackle issue of under-nutrition by improving dietary intake of beneficiaries including- 5.1. Nutrition specific 5.2. Nutrition sensitive
Nutrition specific Folic acid supplementation
Iron supplementation
Iron and folic acid supplementation
Multiple micronutrient supplementation
Calcium supplementation
Iodine supplementation
Iodine fortification
Energy and protein supplementation
Delayed cord clamping
Neonatal vitamin K administration
Neonatal vitamin A supplementation
Kangaroo mother care
Promotion of breast feeding and supportive strategies
Promotion of dietary diversity and complementary feeding
Vitamin A supplementation in children
Iron supplementation for infants and children
Multiple micronutrient supplementation in children
Preventive zinc supplementation in children
Prevention and treatment of SAM- facility based & community based management
Fortification of staple foods and specific foods
Cash transfer programs
Community based platforms for nutrition education and promotion
Integrated management of childhood illness
School based delivery platforms
Child health days
Nutrition interventions in humanitarian emergency settings
Lipid based nutrient supplements
Maternal vitamin D supplementation
Omega-3 fatty acid supplementation in pregnancy
Nutrition sensitive Agriculture
Home gardens and homestead food production systems
24
Fortification
Social safety nets
Conditional cash transfers
Unconditional transfers
School feeding programs
In- kind household food distribution
Transfer programs in emergencies
Early child development
Food security
Water, sanitation and hygiene
6. Comparators: Will include all SRs irrespective of they had a comparison group or not. 7. Outcomes: SRs which have included at least one of these outcomes that reflect
7.1. Nutritional and dietary intake 7.2. Status of factors which affect dietary intake 7.3. Health status
Dietary and nutritional status Factors affecting dietary intake Health status
Weight for Age
Height for Age
Weight for Height
MUAC
BMI
Haemoglobin
Income
Feeding practices
Dietary diversity
Food frequency
Food security
Mortality
Fever
Diarrhea,
Respiratory tract infection
Cognitive and mental development
8. Context: Population from LMICs, these will be classified according to the World Bank definition
(World Bank, 2016)
Exclusion Criteria
Studies will be excluded if they
1. Language: are not published in English
2. Date of publication: not published between Jan 2000 to May 2016
3. Types of SRs: not a systematic review. E.g. they have not 3.1. Searched at least two electronic databases and included a method describing how the
studies were included and/or excluded 3.2. Synthesised primary evidence on the effectiveness of nutrition programs in LMICs and
draw conclusions based on findings from individual studies irrespective of the study designs of the included primary studies
4. Population: do not focus on the general population with a specific focus on vulnerable groups such as children, women and other socio-economically disadvantaged groups. E.g.
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4.1. Participants with conditions like, Tuberculosis, HIV/AIDS, infectious diseases (malaria,
hepatitis and typhoid), communicable diseases (diabetes, CVDs, chronic respiratory
diseases, cancer).
5. Interventions: SRs which have not included at least one of these interventions that aim to tackle issue of under-nutrition by improving dietary intake of beneficiaries including-(see inclusion criteria)
6. Outcomes: SRs which have not included at least one of these outcomes that reflect 6.1. Nutritional and dietary intake 6.2. Status of factors which affect dietary intake 6.3. Health status
26
APPENDIX 2.2 LIST OF DATABASES
Databases (18) Global (11) 1. Annual Reviews Biomedical 2. CINAHL 3. Cochrane Library 4. Global Health 5. Google Scholar 6. IBSS 7. Medline 8. PsycINFO 9. PUBMED 10. The Knowledge Genie 11. Web of Science
Regional (7) 1. African Journals Online
(AJOL) 2. Bangladesh Journals Online
(BanglaJOL) 3. DELNET 4. Indian Citation Index (ICI) 5. LILACS 6. Nepal Journals Online
(NepJOL) 7. PakMediNet
SR Databases (8) 1. 3ie 2. Campbell Collaboration Library for SR 3. Cochrane Database of SRs 4. Database of abstracts of reviews of effects 5. DFID 6. EPPI-Centre-Evidence 7. Joanna Briggs Institute 8. PROSPERO
Digital Library (3) 1. Bioline International 2. HINARI (WHO) 3. WHO Library and Information Networks for Knowledge (WHOLIS)
27
APPENDIX 2.3 SEARCH STRATEGY
Depending on the data base, we will use a combination of free text terms and MeSH terms
INTERVENTIONS [Initial search with intervention terms only]
Intervention* OR initiative* OR process* OR program* OR policy OR policies OR effect* OR "delivery mode"
OR implication* OR scheme* OR strategy* OR outcome* OR impact OR evaluat* OR delivery OR
implement*
AND
Nutrition* OR "maternal and child health" OR "maternal and child nutrition" OR "MNCH" OR
“fortification” OR “single nutrient fortification” OR "folic acid supplementation" OR "iron supplementation"
OR "multiple micronutrient powder" OR "early childhood development" OR “micronutrient
supplementation” OR “micronutrient powders” OR “micronutrient sprinklers” OR "calcium
supplementation" OR "iodine supplementation" OR "iodine fortification" OR “energy protein
supplementation” OR "delayed cord clamping" OR "neonatal vitamin K administration" OR "neonatal
vitamin A supplementation" OR "kangaroo mother care" OR “early initiation of breastfeeding” OR
"promotion of breastfeeding" OR “responsive feeding” OR "promotion of dietary diversity" OR
"complementary feeding" or "complementation" OR "vitamin A supplementation" OR "multiple
micronutrient supplementation" OR "preventive zinc supplementation" OR “SAM” OR "facility based
management" OR "community based management” OR "staple foods fortification" OR "home based
fortification" OR "specific foods fortification" OR "cash transfer programs" OR "community based
platforms” OR “nutrition education” OR “nutrition promotion" OR “IMNCI” OR "integrated management
childhood illness" OR "school based programs" OR “LNS” OR "lipid based nutrient supplements" OR
“ready-to-eat foods” OR “RUTF” OR “ready-to-eat therapeutic foods” OR “ready-to-eat supplementary
foods” OR “RUSF” OR "vitamin D supplementation" OR " Omega-3 fatty acid supplementation" OR
"nutrition sensitive" OR "home gardens” OR “home gardening” OR “kitchen garden” OR “vegetable
garden” OR “household garden” OR “household gardening” OR “garden based nutrition program” OR
“kitchen garden” OR “kitchen gardening” OR “project garden” OR “homestead plot” OR "homestead
horticulture and gardening" OR “food garden” OR “food gardening” OR “home based food garden” OR
“homestead food production” OR “homestead food production systems" OR "fortification" OR “bio-
fortification” OR "social safety nets" OR “family allowance program” OR “child grant” OR “child support
grant” OR “microfinance” OR “social transfer” OR “social assistance” OR “cash transfer” OR "conditional
cash transfers" OR “monetary incentives” OR "unconditional transfers" OR "in-kind household food
distribution" OR " transfer programs emergencies" OR “feeding” OR “school feeding” OR “meals” OR
“snacks” OR “breakfast” OR “mid-day meal” OR “mid day meal” OR “feeding services” OR “lunch” OR
28
"school feeding programs" OR “mot or development” OR "food security" OR “food supply” OR “food
distribution” OR “food production” OR “food aid” OR “sustainable agriculture” OR "WASH" OR “water or
sanitation and hygiene”
CONTEXT
“developing countries” OR “less developed countries” OR “underdeveloped” OR “underserved countries” OR “deprived countries” OR “poor countries” OR “third world countries” OR “transitional countries” OR “low income countries” OR “middle income countries” OR “lower middle income countries” OR “upper middle income countries” OR “low and middle income countries” OR “lesser developed countries” OR “developing nation” OR “developing economies” OR “LMICs” OR “LAMI countries” OR Africa* OR Asia* OR “Caribbean” OR “West Indies” OR “South America” OR “Latin America” OR “Central America” OR “Sub-Saharan Africa” OR “underprivileged countries” OR “Afghanistan” OR “Albania” OR “Algeria” OR “American Samoa” OR “Angola” OR “Armenia” OR “Armenian” OR “Azerbaijan” OR “Bangladesh” OR “Belarus” OR “Byelarus” OR “Byelorussian” OR “Belorussian” OR “Belorussia” OR “Belize” OR “Benin” OR “Bhutan” OR “Bolivia” OR “Bosnia” OR “Herzegovina” OR “Hercegovina” OR “Botswana” OR “Brazil” OR “Bulgaria” OR “Burkina Faso” OR “Burkina Fasso” OR “Burundi” OR “Urundi” OR “Cabo Verde” OR “Cape Varde” OR “Cambodia” OR “Cameroon” OR “Cameroons” OR “Cameron” OR “Camerons” OR “Central African Republic” OR “Chad” OR “China” OR “Colombia” OR “Comoros” OR “Comoro Islands” OR “Com ores” OR “Congo” OR “Democratic Republic Congo” OR “Costa Rica” OR “Cote” OR “d'Ivoire” OR “Ivory Coast” OR “Cuba” OR “Djibouti” OR “Dominica” OR “Dominican Republic” OR “Ecuador” OR “Egypt” OR “United Arab Republic” OR “El Salvador” OR “Eritrea” OR “Ethiopia” OR “Fiji” OR “Gabon” OR “Gabonese Republic” OR “Gambia” OR “Georgia” OR “Georgia Republic” OR “Georgian Republic” OR “Ghana” OR “Grenada” OR “Guatemala” OR “Guinea” OR “Guinea-Bisau” OR “Guyana” OR “Haiti” OR “Honduras” OR “India” OR “Indonesia” OR “Iran” OR “Islamic Republic” OR “Iraq” OR “Jamaica” OR “Jordan” OR “Kazakhstan” OR “Kazakh” OR “Kenya” OR “Kiribati” OR “Korea” OR “Democratic People's Republic Korea” OR “Kosovo” OR “Kyrgyz Republic” OR “Kyrgyzstan” OR “Kirgizstan” OR “Kirghizia” OR “Krghiz” OR “Lao PDR” OR “Lebanon” OR “Lesotho” OR “Liberia” OR “Libya” OR “Macedonia” OR “Madagascar” OR “Malawi” OR “Malaysia” OR “Maldives” OR “Mali” OR “Marshall Islands” OR “Mauritania” OR “Mauritius” OR “Mexico” OR “Micronesia” OR “Federated States Micronesia” OR “Moldova” OR “Moldovia” OR “Mongolia” OR “Montenegro” OR “Morocco” OR “Mozambique” OR “Myanmar” OR “Myanmar” OR “Burma” OR “Namibia” OR “Nepal” OR “Nicaragua” OR “Niger” OR “Nigeria” OR “Pakistan” OR “Palau” OR “Panama” OR “Papua New Guinea” OR “Paraguay” OR “Peru” OR “Philippines” OR “Romania” OR “Rumania” OR “Roumania” OR “Rwanda” OR “Ruanda” OR “Samoa” OR “Sao Tome” OR “Principe” OR “Senegal” OR “Serbia” OR “Sierra Leone” OR “Solomon Islands” OR “Somalia” OR “South Africa” OR “South Sudan” OR “Sri Lanka” OR “Ceylon” OR “St. Lucia” OR “Saint Lucia” OR “St. Vincent” OR “Saint Vincent” OR “Grenadines” OR Sudan* OR Surinam* OR “Swaziland” OR “Syrian Arab Republic” OR “Syria” OR “Tajikistan” OR “Tadzhikistan” OR “Tadjikistan” OR “Tadzhik” OR “Tanzania” OR “Thailand” OR “Timor-Leste” OR “Timor Leste” OR “Togo” OR “Tonga” OR “Tunisia” OR “Turkey” OR “Turkmenistan” OR “Tuvalu” OR “Uganda” OR “Ukraine” OR “Uzbekistan” OR “Uzkek” OR “Vanuatu” OR “Vietnam” OR “Viet Nam” OR “West Bank” OR “Gaza” OR “Yemen” OR “Zambia” OR “Zimbabwe”
STUDY DESIGN
"systematic review" OR “SLR” OR meta-analysis* OR meta-review* OR meta- regression* OR meta-synthesis* OR "realistic review" OR “descriptive review” OR “research review” OR “thematic review” OR “explanatory review” OR "narrative review" OR "integrative review" OR "mixed method review" OR "qualitative review" OR "quantitative review" OR "research synthesis" OR “evaluation review” OR “evidence mapping” OR “evidence map review” OR “impact review”
29
EXAMPLE OF SEARCH CONDUCTED ON DATABASE (PUBMED, 1917 hits)
30
EXAMPLE OF SEARCH CONDUCTED ON DATABASE (Cochrane Library, 2417 hits)
31
APPENDIX 2.4: QUALITY ASSESSMENT TOOL
Items
1. Was an ‘a priori’ design provided? a) ‘A priori’ design b) Statement of inclusion criteria c) PICO/PIPO research question (population, intervention, comparison, prediction, outcome)
2. Was there duplicate study selection and data extraction? a) There should be at least 2 independent data extractors as stated or implied b) Statement of recognition or awareness of consensus procedure for disagreement c) Disagreements among extractors resolved properly as stated or implied
3. Was a comprehensive literature search performed? a) At least 2 electronic sources should be searched b) The report must include years and databases used (e.g. CENTRAL, MEDLINE, EMBASE) c) Keywords or MESH terms (or both) must be stated AND where feasible the search strategy outline
should be provided such that one can trace the filtering process of the included articles d) In addition to the electronic database (PubMed, ,MEDLINE, EMBASE), all searches should be
supplemented by consulting current contents, review, textbooks, specialized registers, or experts in the particular field of study, and by reviewing the references in the studies found.
e) Journals were “hand –searched” or “manual searched” (i.e. identifying highly relevant journals and conducting a manual, page by page search by their entire contents looking for potentially eligible studies)
4. Was the status of publication (i.e. grey literature) used as an inclusion criterion? a) The authors should state that they searched for reports regardless of their publication type b) He authors should state whether or not they excluded any reports (from the systematic review),
based on their publication status, language, etc. c) “Non -English papers were translated” or readers sufficiently trained in foreign language d) No language restriction or recognition of non-English articles
5. Was a list of studies (included or excluded) provided? a) Table/ list/ figure of included studies, a reference list does not suffice b) Table/ list/ figure of excluded studies, either in the article or in a supplement source (i.e. online).
(Excluded studies refer to those studies seriously considered on the basis of title and/or abstract, but rejected after reading the body of the text)
c) Author satisfactorily/ sufficiently stated the reason for exclusion of the seriously considered studies d) Reader was able to retrace the included and excluded studies anywhere in the article bibliography,
reference or supplemental source
6. Were the characteristics of the included studies provided? a) In an aggregated form such as a table, data from the original studies should be provided on the
participants, intervention and outcomes. b) Provide the ranges of relevant characteristics in the studies analysed (e.g. age, race, sex, relevant
socio economic data, disease status, duration, severity or other diseases should be reported) c) The information provided appears to be complete and accurate (i.e. there was a tolerable range of
subjectivity here. Is the reader left wondering? If so, state the needed information and reasoning)
7. Was the scientific quality of the included studies assessed and documented? a) ‘A priori’ method of assessment should be provided (e.g. for effectiveness studies if the author(s)
chose to include only randomized, double- blind, placebo controlled studies, or allocation concealment as inclusion criteria); for other types of studies alternative items will be relevant
32
b) The scientific quality of the included studies appeared to be meaningful c) Discussion/ recognition/ awareness of level of evidence d) Quality of evidence should be rated/ ranked based on the characterized instruments, (Characterized
instrument is a created instrument that ranks the level of evidence. e.g. GRADE (Grading of Recommendations Assessment, Development and Evaluation)
8. Was the scientific quality of the included studies used appropriately in formulating conclusions? a) The results of the methodological rigor and scientific quality should be considered in the analysis and the
conclusion of the review b) The results of the methodological rigor and scientific quality were explicitly stated in formulating
recommendations c) To have conclusions integrated/ drives towards a clinical consensus statement d) This clinical consensus statement drives towards revision or confirmation of clinical practice guidelines
9. Were the methods used to combine the findings of studies appropriate? a) Statement of criteria that were used to decide that the studies analysed were similar enough to be
pooled? b) For the pooled results, a test should be done to ensure studies were combinable, to assess their
homogeneity (i.e. Chi2 test for homogeneity, I2 statistics) c) Is there a recognition of heterogeneity of lack of thereof d) If heterogeneity exists a “random- effects model” should be used or the rationale (i.e. clinical
appropriateness) of combining should be taken into consideration (i.e. is it sensible to combine?), or stated explicitly (or both)
e) If homogeneity exists, author should state a rationale or a statistical test
10. Was the likelihood of the publication bias (a.k.a “file drawer” effect) assessed? a) Recognition of publication bias or file drawer effect b) An assessment of publication bias should include graphical aids (e.g. funnel plot, other available tests) c) Statistical tests (e.g. Egger regression test)
11. Was the conflict of interest stated? a) Statement of sources of support b) No conflict of interest. This is subjective and may require some deduction or searching c) An awareness/ statement of support or conflict of interest in the primary inclusion studies
33
APPENDIX 2.5: DATA EXTRACTION TOOL
Part 1: Full text screening sheet Part 2: Data extraction sheet for the included full text of systematic reviews
PART 1 1. Full test screening sheet
Screening Full text ( )
Study ID: Data extractor ID: Date form completed:
First author: Year of study:
Citation:
1.1 General information
Publication type: Journal article ( ) Conference presentation ( ) Other (specify) _____________
Funding source of systematic review:
Potential conflict of interest from funding: Yes ( ) No ( ) unclear ( )
Title:
Aim/objectives:
Setting:
Search Period:
1.2 Systematic review eligibility
Systematic review characterises Page/Para/ Figure No.
Type of study (review authors to add/remove designs based on criteria specified in the protocol)
Is it a systematic review: Yes ( ) No ( ) Unclear ( ) Description:
Population Specify population (as mentioned in the systematic review) included: Does the population meets the criteria for inclusion? Yes ( ) No ( ) → Exclude Unclear ( )
Intervention Intervention included: Does the intervention meets the criteria for inclusion? Yes ( ) No ( ) → Exclude Unclear ( )
Outcomes Tick mark outcomes mentioned in systematic review: 1. Dietary and nutritional
status
Weight for Age
Height for Age
Weight for Height
MUAC
BMI
Haemoglobin
Other outcomes: List the outcomes as defined in systematic review
34
2. Factors affecting dietary intake
Income
Feeding practices
Dietary diversity
Food frequency
Food security 3. Health status
Mortality
Fever
Diarrhoea
Respiratory tract infection
Cognitive and mental development
Do the outcome meet the criteria for inclusion
Yes ( ) No ( ) → Exclude Unclear ( )
1.3 Summary of assessment for inclusion
Include in overview ( ) Exclude from overview ( )
Independently assessed, and then compared Yes ( ) No ( )
Differences resolved by discussion Yes ( ) No ( ) Not Applicable ( )
Differences resolved by considering opinion of third investigator Yes ( ) Not applicable ( )
Third investigator ID:
Request further details Yes ( ) No ( )
Contact details of systematic review authors:
Any reply from systematic review authors
Reason for exclusion/inclusion
PART 2
2 Data extraction sheet for the included full text of systematic reviews
Study ID: Data extractor ID: Date form completed:
First author: Year of study:
Citation:
2.1 General information
Publication type: Journal article ( ) Conference presentation ( ) Other (specify) _____________
Funding source for the study:
Potential conflict of interest from funding: Yes ( ) No ( ) unclear ( )
Country (ies):
Setting:
Title:
Aim/objectives:
Relevant references from systematic review to be traced: 1. 2.
35
3.
Inclusion and exclusion criteria of systematic review
Study design:
Participants:
Interventions:
Comparison:
Outcome:
Study design included and number of studies:
2.2 Participants
Participants Information for each group Page/Para/ Figure No.
Participants Specify the population (as mentioned in systematic review) included:
Number of participants in the review
Area covered (households, district etc.)
Rural or urban
Number of participants considered for analysis of the review
Age (provide mean or median or range)
2.3 Intervention (Intervention 1)
Intervention Nutrition specific intervention Page/Para/ Figure No.
Description of intervention (as defined in the systematic review)
Co-intervention if any Any other intervention apart from nutrition
Theoretical basis (include key references)
Is theoretical framework for designing the interventions explicitly mentioned? No If yes, whether intervention include single theoretical framework or multiple frameworks are grouped together. Which theories are used? [include with references]
Did the intervention include strategies to improve nutritional status of children by improving dietary intake and feeding practices
If yes, describe:
Level at which intervention delivered-
Group/Community
Place where intervention delivered-
Setting: facility/institution, home, community etc.
Duration of delivery Frequency (weekly/monthly/yearly): Duration (weekly/monthly/yearly):
Medium of delivery
Subgroups Describe if any subgroup is considered in the review
36
Control/comparison
Other factors (given along with nutrition) which can influence the outcome
Note: This table is extend if there are more interventions in the systematic review (e.g. Nutrition sensitive interventions) 2.4 Outcomes List the outcomes assessed by systematic review
1. ____________________________ 2. ____________________________ 3. ____________________________ 4. ____________________________ 5. ____________________________
Outcome 1
Question Page/Para/ Figure No.
Outcome defined
Number of studies included in systematic review specific to this outcome
Number of participants specific to this outcome
At which level the outcome (individual/group) is measured
Time points measured
Time points reported
How is the outcome reported Self or study assessor Cost of source of external support reported?
Note: This table will extend if there are more outcomes in the systematic review 2.5 Quantitative analysis Outcome 1
Results Page/Para/ Figure No.
Whether meta-analysis performed Yes ( ) No ( )
If no meta-analysis, reasons for the same
If meta-analysis performed, effect measures
Heterogeneity Identified Not identified
Test used Results
Homogeneity Identified Not identified
Test used Results
GRADE
ITT (Intention to treat analysis) Yes ( ) No ( ) Description
If no meta-analysis, describe the result
Conclusion
Note: This table will extend if analysis is performed for more than one outcomes
37
2.6 Methodological quality
Risk of bias Tool used
Description
Effectiveness of nutrition interventions if mentioned in the discussion criteria
Conclusion of systematic review
Recommendations
38
APPENDIX 2.6: LIST OF STAKEHOLDERS
Organization Office Contact person Designation Address
BMGF
India Nachiket Mor Director, India Office
Bill & Melinda Gates Foundation, Capital Court, 3rd Floor, Olof Palme Marg, Munirka, Delhi 91-11-4713-8800 http://www.gatesfoundation.org/Where-We-Work
BRAC Nepal Rafiqul Islam
Country Representative
BRAC Nepal: Pavitra Niwas, Chapali Bhadrakali 08, Budhanilkantha, Kathmandu, Nepal. Phone: 977 9861482772. E-mail: [email protected]
Pakistan Muzaffar Uddin
Country Representative
Muzaffar Uddin Country Representative Plot No. 05, Street No. 09, Fayyaz Market Sector G-8/2 Islamabad Pakistan Tel: 92 51 2263376-80 E-mail: [email protected]
Afghanistan M Anowar Hossain
Country Representative
House # 472, Lane # 2 Hazi Mir Ahmed Street Baharistan, Karte Parwan Kabul Afghanistan Cell: 93 (0) 700288300 Email: [email protected]
Myanmar Kazi Faisalbin Seraj
Country Representative
Kyun Shwe Myaing-2 Street Boyoke Ywa, Thingangyun Township Yangon, Myanmar Tel: 95(1) 578236
Bangladesh (Hq)
Faruque Ahmed
Executive Director BRAC International
BRAC Centre, 75 Mohakhali, Dhaka-1212, Bangladesh Tel: 880-2-9881265, 8824180-7. Ext: 3155, 3107, 3161 E-mail: [email protected]
DFID South Asia - - DFID South Asia Research Hub (SARH) British High Commission, Shantipath, Chanakyapuri, New Delhi, 110021, India Phone: +91 11 2419 2100
FAO Afghanistan Shichiri, Mr Tomio FAO Representative
www.fao.org/countryprofiles/index/en/?iso3=AFG
Bangladesh Robson, Mr Michael Thomas
FAO Representative
Email: [email protected] www.fao.org/bangladesh
39
India Khadka, Mr Shyam Bahadur
FAO Representative
Email:[email protected] www.fao.org/india
Myanmar Bui, Ms Lan Thi FAO Representative
Email: [email protected] www.fao.org/myanmar
Nepal Pipoppinyo, Mr Somsak
FAO Representative
Email: [email protected] www.fao.org/nepal
Pakistan
Evans, Mr Patrick FAO Representative
Email: [email protected] www.fao.org/pakistan
FHI360 Bangladesh Shamim Jahan
Chief of Party, SIKHA Project
FHI 360 Bangladesh Office Road 35 House 5, Gulshan 2 Dhaka, Bangladesh 1212 Telephone: +88.02.9887561 Email: [email protected]
India Bitra George
Country Director
FHI 360 India Office, H-5 Green Park Extension Ground Floor New Delhi 110 016 India Telephone: +91.11.4048.7777 Email: [email protected]
Myanmar Khin Zarli Aye
Country Director
FHI 360 Myanmar (Burma) Office, 133 Mawyawaddi Street, 8 Mile, Mayangone Township, Yangon, Myanmar Telephone: +95.1.666 432 Email: [email protected]
Afghanisthan Wahid Omar
Chief of Party, University Support and Workforce Development Program
P.O. Box 5161, Central Post Office, Kabul, Afghanistan Telephone: +93(0)785854765 Email: [email protected]
Nepal Satish Raj Pandey
Country Director
FHI 360 Nepal Office, GPO Box 8803 Gopal Bhawan, Anamika Galli Ward-4 Baluwatar, Kathmandu Nepal Telephone: +977.1.4437173 Email: [email protected]
GAIN Afghanisthan - - Kabul, Afghanistan, 302, Street 6, (Navoi Street), Lane 3, Police District 10, Qala-e-Fatehullah Khan, Kabul, Afghanistan T +93 20 22 00 773
Bangladesh Rudaba Khondker Country Director
Dhaka, Bangladesh, Flat No. A – 3 (3rd Floor), Suvastu Asmi Nazeela Monor, House # NE(B) 2/1, Road # 71 North Gulshan 2, Dhaka-1212, Bangladesh T +880 171 94 00 229
India Tarun Vij Country Director
New Delhi, India, Suite 15 AB, AMAN New Delhi
40
Lodhi Road, New Delhi – 110003, India T +91 11 43147575
Pakistan Sajjad Imran Country Director
Islamabad, Pakistan, House No. 14, Street 37, Sector F-7/1, Islamabad, Pakistan +92 51 831 3981-82
ICDDR,B Bangladesh Zulfiqar A. Bhutta Child health and nutrition experts
GPO Box 128, Dhaka 1000, Bangladesh Phone: (+88 02) 9827001–10 Email: [email protected] [email protected] Email: [email protected]
LANSA Afghanistan, Bangladesh, India, Pakistan
Madhura Swaminathan
Member of consortium steering group
Chairperson, 3rd Cross Street, Institutional Area, Taramani, Chennai 600 113, India Tel: +91 (44) 22541229, +91 (44) 22541698 Email: [email protected] Email: [email protected] http://www.lansasouthasia.org/
MI Afghanistan Dr. M Ibrahim Shinwari
Director, Afghanistan
c/o South Asia Development Excellence, Consultants (SADEC), Charrahi Haji Yaqub, Doost Tower, Apartment 11, Kabul, Afghanistan Email: [email protected]
Bangladesh Dr. S. M. Mustafizur Rahman
Country Director, Bangladesh
Apartment 102, House 06 (Lake View), Road 104, Gulshan 2, Dhaka 1212, Bangladesh T: +880 2 989 9896, Ext 2013 Email: [email protected]
India Sucharita Dutta
Director, India B-28, Qutab Institutional Area, 2nd Floor, Tara Crescent, New Delhi – 110016, India T: +91 11 46862000 Email: [email protected]
Nepal Macha Raja Maharjan
Director, Nepal Uttar Dhoka Marg, 424/2, 2nd floor, Lazimpat, Kathmandu, P.O. Box 23874 T: +977 1 4001083
41
Email: [email protected]
Pakistan Dr. Naseer Muhammad Nizamani
Director, Pakistan
House 02, Street 54, Sector F-8/4, Islamabad, Pakistan 44000 T: +92 51 285 5886-7 Email:[email protected]
SUN Bangladesh Ms. Roxana Quader
Additional Secretary Ministry of Health and Family Welfare
Email: [email protected] http://scalingupnutrition.org/
Myanmar Soe Lwin Nyein
Director General Department of Public Health, Ministry of Health
DR SOE LWIN NYEIN (CHAIR) DIRECTOR GENERAL (DEPARTMENT OF PUBLIC HEALTH) - MINISTRY OF HEALTH PHONE : +95 67 411389+95 67 411389 E-MAIL : [email protected] http://scalingupnutrition.org/
Nepal Madhu Kumar Marasini
Joint Secretary, National Planning Commission Secretariat
Email: [email protected] http://scalingupnutrition.org/
Pakistan Muhammad Aslam Shaheen
Chief of Nutrition, Planning and Development Division, Planning Commission
Email: [email protected] http://scalingupnutrition.org/
TN UK Stuart Gillespie CEO, Transform Nutrition
Transform Nutrition Research Programme Consortium, Institute of Development Studies Library Road, Brighton BN1 9RE Email: [email protected] Email: [email protected]
UNICEF Afghanistan - - UNICEF, P.O. Box 54, Kabul, Afghanistan 93 7 9050.7000 Email: [email protected]
Bangladesh - - UNICEF, P.O. Box 58, Dhaka - 1000 People's Republic of Bangaldesh
42
880 2 5566-8088 -PABX Ext. 7001 [email protected]
India - - United Nations Children's Fund, 73 Lodi Estate New Delhi 110 003, India 91 11 2469.0401 Email: [email protected]
Myanmar Mr. Bertrand Bainvel
UNICEF Representative in Myanmar
UNICEF MYANMAR P.O. Box 1435, Yangon 11201, Myanmar +95 1 230 5959 +95 1 230 5959 (Representative's direct line) 95 1 230.5960 Email: [email protected]
Nepal - - United Nations Children's Fund, Nepal Country Office, P.O.Box 1187, UN House, Pulchowk, Kathmandu, Nepal Tel: 977-1-5523200, Fax: 977-1-5527280 Email: [email protected]
Pakistan Angela Kearney UNICEF Representative
UNICEF, P.O. Box 1063, Islamabad, Pakistan 92 51 209.7700-7798 92 51 209.7800-7895 Email:[email protected]
WFP Afghanistan - - WFP Country Office, Afghanistan, Darya Village Hawashenasi Street, Besides Kabul Airport, Kabul, Afghanistan, PO BOX 1093 Phone: +93 (0) 700 28 28 24 & +93 (0) 797 66 20 05 Email: [email protected]
Bangladesh - - Dhaka, IDB Bhaban 14th, 16th and 17th Floor E/8-A, Rokeya Sharani Agargaon, Sher-e-Bangla Nagar, Dhaka-1207 Phone: +880 2 91830-22 /-23 /-24 /-25 Email: [email protected]
India - - New Delhi, World Food Programme, 2 Poorvi Marg, Vasant Vihar, New Delhi 110057 Phone: +91 11 26150000 Email: [email protected]
Myanmar - - Yangon Country Office, No. 5 Kanbawza Street, Shwe
43
Taung Kyar (2) Ward, Bahan Township, Yangon, Myanmar Phone: +95 1 230 5971~6 (6 lines) Email: [email protected]
Nepal Ertharin Cousin Executive Director
Kathmandu, P.O. Box No 107, Chakupat, Patan Dhoka, Lalitpur, Kathmandu, Nepal Phone: +977 1 5260607 Email: [email protected]
Pakistan - - Islamabad, Plot no. 1, Diplomatic Enclave No 1, Sector G-5, Islamabad. Phone: Tel: +92-51-8312000 Email: [email protected]
WHO Afghanistan Peeperkorn, Dr Richard
WHO representative
UNOCA Compound, Jalalabad Road Pul-e-Charkhi Kabul, Afghanistan Telephone: +93700045276 Email: [email protected]
Bangladesh Paranietharan, Dr Navaratnasamy
- Country Office for Bangladesh, United House (GF to 3rd Floor), 10 Gulshan Avenue, Gulshan-1, Dhaka-1212, Bangladesh, PO Box: 250 Telephone: (+8802) 8831415 or (+880) 09604027200 Hunting Email: [email protected]
India Henk Bekedam Country representative
Office of the WHO Representative to India, 537, A Wing, Nirman Bhawan, Maulana Azad Road, New Delhi 110 011, India Email: [email protected]
Myanmar Luna, Dr Jorge Mario - PO Box 14 11061 - Yangon, Myanmar Telephone: +95 1 650386 Email: [email protected]
Nepal Vandelaer, Dr Jos - POB 108 Kathmandu, Nepal Telephone: +977 15523200 Email: [email protected]
Pakistan Thieren, Dr Michel - PO Box 1013 Islamabad, Pakistan Telephone: +92 51 843 2451 Email: [email protected]
44
Ministry of Health Afghanistan Dr. Ferozuddin Feroz, Public Health Minister, Government of the Islamic Republic of Afghanistan
Ministry of Public Health, Kabul, Afghanistan Email: [email protected] Email: http://moph.gov.af/en/page/ministers-biography
Bangladesh Mr. Mohd. Nasim Mr. Zahid Malek Mr. Syed Manjurul Islam
Hon Minister of Health & FW Honourable Minister of State, Health & FW Secretary, Health & FW
9574488, 9574422, Email: [email protected] 9545515, 9540461, Email: [email protected] 9574490, 9540469 Email: [email protected] Email: [email protected]
India Shri Jagat Prakash Nadda
Union Minister Health & Family Welfare
Room No. 348; ‘A’ Wing, Nirman Bhavan, New Delhi-110011 011-23063024, 011-23063513, 011-23061661 Email: [email protected]
Myanmar Prof. Dr Thet Khaing Win
Secretary (Ministry of Health)
Prof. Dr Thet Khaing Win (Member) Permanent Secretary (Ministry of Health) Phone : +95 67 411357 E-mail : [email protected] Dr Soe Lwin Nyein (Member), Director General (Department of Public Health) - Ministry of Health Phone : +95 9 067 411388+95 67 411389 E-mail : [email protected]
Nepal Mr. Ram Janam Chaudhari Shanta Bahadur Shrestha
Hon'ble Minister Secretary
Ministers Secretariat Phone no. 426-2534, 426-2543 ext-242 Email: [email protected] Email: [email protected]
Pakistan Ms Sherry Rehman Federal Minister of Health
Health Division. Block "C". Pak. Secretariat, Islamabad. Int.+9251 9213933 Email: http://www.health.gov.pk